1701006041 CASE PRESENTATION
LONG CASE
CHIEF COMPLAINTS
80 years old male resident of marrigudem, agriculture labourer by occupation came to OPD with the chief complaints of
i)Fever - since 3 days
ii)One episode of vomiting 2 days back
iii)Decreased urine output associated with burning micturition since - since 2 days
History of presenting illness
patient is apparently asymptomatic 3 days back.
I)He has Fever :
insidious in onset
Gradually progressive
with no diurnal variations
Relieved on medication
Associated with chills, rigors and generalised body pains. It is not associated with cough, cold, shortness of breathe, night sweats.
II)An episode of vomiting:
2 days back
Content:Food
Non bilious and not foul smelling
III)Decreased urine output and burning micturition
Burning micturition experienced at start of the urine and relieved after the urination
Decreased urine output since 2 days no hematuria association
Past history:
He was with similar complaints in the past 10years ago, then he consulted a local doctor and relieved on medication (may be antibiotics). And there is continuation of such episodes then refered to higher hospital and diagnosed with renal problem (AKI) which was treated with dialysis once and given some diuretics as he is suffering from oliguria.
He has a recurrent episodes of fever with burning micturition later also.
He is known case of hypertension since 24years. Not a known case of diabetes, tuberculosis,asthma and epilepsy.
Surgical history
He underwent a nephrectomy surgery 27yrs ago donated to his brother.
Personal history
Appetite - normal
Diet- mixed
Sleep - adequate
Bowel - regular
Bladder - oliguria since 2 days, associated with burning micturition, feeling of incomplete voiding.
Allergies- none
Addiction- 3 beedi/ day from 27yrs of age
Alcohol- occasionally
Stopped both alcohol and smoking after the nephrectomy surgery.
General examination:
Patient is conscious, coherent, co operative and well oriented to time, place, and person
moderately build and nourished.
PALLOR: Present
ICTERUS:. Absent
CYANOSIS:. Absent
CLUBBING:. Absent
LYMPHADENOPATHY: Absent
PEDAL EDEMA:. Present
There was pedal edema
Gradually progressive
Pitting type
Bilateral
Below knees
No local rise of temperature and tenderness
Grade 2
Not relived on rest
Not associated with any cardiac, hepatic, venous and respiratory causes.
Vitals:
Febrile 99.2F
Bp- 150/90 mmHg ( on medication)
Pulse rate - 76 BPM
Systemic examination:
CVS examination
No visible pulsations, scars, engorged veins.
No rise in JVP
Apex beat is felt at 5 ics medial to mid clavicular line.
S1 S2 heard . No murmurs.
Respiratory system examination
Shape of chest is elliptical, b/l symmetrical.
Trachea is central.
Expansion of chest is symmetrical
Bilateral Airway E - positive
Per abdomen examination
No visible pulsations and scars swellings.
Soft, non tender, no organo megaley.
Umbilicus is inverted.
CNS EXAMINATION:
Conscious
Speech normal
No signs of meningeal irritation
Cranial nerves: normal
Sensory system: normal
Motor system: normal
Reflexes: Right. Left.
Biceps. ++. ++
Triceps. ++. ++
Supinator ++. ++
Knee. ++. ++
Ankle ++. ++
Gait: normal
Investigations:
ECG:
50 year old male with
▪weakness of both lower limbs
and slurring of speech since 5 days
HISTORY OF PRESENTING ILLNESS
Patient had a history of fall 1 year ago and he did not take any treatment for it and was alright for 8 months then 4 months back he had pain in right hip which was insidious in onset and gradually progressive in nature
since 1month there was change in the gait of patient which was noticed by his relatives and there is hematuria for 5 days which he has neglected
For which he consulted local doctor and diagnosed avascular necrosis of of femur for which he has given medication
After taking medication he developed weakness of both lower limbs but more on right side where he could not walk, stand and eat and he need assistance for these activities
PAST HISTORY
Known case of diabetes since 12 years and takes insulin daily 2 times ( 15 U before breakfast, 10 U in the evening)
not a known case of hypertension, asthma , TB, epilepsy
PERSONAL HISTORY
Diet- mixed
Appetite- normal
Sleep - Adequate
Bowel and bladder movements- regular
Addiction- smoker since 12 years takes 1 beedi per day and stopped for 4 years and again started smoking from 1 year
consumed alcohol nearly for 20 years and stopped taking it
FAMILY HISTORY
Insignificant
GENERAL EXAMINATION
Patient is conscious coherent cooperative, well oriented to time place person
Moderately built and moderately nourished
Pallor- mild
icterus- absent
cyanosis- absent
clubbing- absent
Lymphadenopathy - absent
Edema- present
On 02/06/2022:
Bp - 120/80mmhg
PR - 92bpm
RR -17cpm
SpO2 -97%
GRBS - 150mg/dl
systemic examination
▪CVS-- s1 ,s2 heard no murmurs
• Respiratory system- normal vesicular breath sounds heard
• Abdomen- no tenderness no. . palpable mass , not distended
On 03/06/2022:
c/c/c and afebrile
CVS - S1 S2+
CNS - Sensorium improved
P/A - soft and non tender
On 04/06/2022:
c/c/c and afebrile
BP - 120/80mmhg
PR - 88bpm
CVS - S1 S2+
CNS - Sensorium improved
On 05/06/2022:
c/c/c
BP - 100/60mmhg
PR - 92bpm
CVS - S1 S2+
CNS - Sensorium improved
R/S - BAE + and LT CREPTS +
P/A - soft and non tender.
On 07/06/2022:
BP - 120/80mmhg
PR - 92bpm
Atrophy of right calf region
sensations of both limbs - intact
absence of mobility of both limbs
Provisional Diagnosis:
Hypokalemic periodic paralysis
INVESTIGATIONS
29/5 /2022
Rt kidney - 8.8 * 4.2 cm
Lt kidney - 10*3.6 cm
Size is normal but increased echotexture
CMD - partially maintained
Spleen - 12.9cm (increased)
Multiple intraductal and parenchymal calcification noted in pancreas involving and head and pancreas.
8mm calculus noted in inferior pole of left kidney.
Distended gall bladder with calcification noted of 6mm.
IMPRESSIONS ON USG
• Cholelithiasis with GB sludge
• chronic pancretitis
• left renal calculus
• mild
splenomegaly
• B/L grade - II RPD changes
• minimal ascitis
4/06/2022
ECG Reports:
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